Eur Spine J (2009) 18:16951705
DOI 10.1007/s00586-009-1146-y
ORIGINAL ARTICLE
The effect of different design concepts in lumbar total disc
arthroplasty on the range of motion, facet joint forces and
instantaneous center of rotation of a L4-5 segment
Hendrik Schmidt Stefan Midderhoff
Kyle Adkins Hans-Joachim Wilke
Received: 9 March 2009 / Revised: 29 June 2009 / Accepted: 16 August 2009 / Published online: 4 September 2009
Springer-Verlag 2009
Abstract Although both unconstrained and constrained
core lumbar artificial disc designs are in clinical use, the
effect of their design on the range of motion, center of
rotations, and facet joint forces is not well understood. It
is assumed that the constrained configuration causes a
fixed center of rotation with high facet forces, while the
unconstrained configuration leads to a moving center of
rotation with lower loaded facets. The authors disagree
with both assumptions and hypothesized that the two
different designs do not lead to substantial differences in
the results. For the different implant designs, a three-
dimensional finite element model was created and sub-
sequently inserted into a validated model of a L4-5
lumbar spinal segment. The unconstrained design was
represented by two implants, the Charite disc and a
newly developed disc prosthesis: Slide-Disc. The con-
strained design was obtained by a modification of the
Slide-Disc whereby the inner core was rigidly con-
nected to the lower metallic endplate. The models were
exposed to an axial compression preload of 1,000 N.
Pure unconstrained moments of 7.5 Nm were subse-
quently applied to the three anatomical main planes.
Except for extension, the models predicted only small
and moderate inter-implant differences. The calculated
values were close to those of the intact segment. For
extension, a large difference of about 45% was calcu-
lated between both Slide-Disc designs and the Charite
disc. The models predicted higher facet forces for the
implants with an unconstrained core compared to an
H. Schmidt (&)
S. Midderhoff
K. Adkins
H.-J. Wilke
Institute of Orthopaedic Research and Biomechanics,
University of Ulm, Helmholtzstrasse 14, 89081 Ulm, Germany
e-mail: h.schmidt@uni-ulm.de
implant with a constrained core. All implants caused a
moving center of rotation. Except for axial rotation, the
unconstrained and constrained configurations mimicked
the intact situation. In axial rotation, only the Slide-
Disc with mobile core reproduced the intact behavior.
Results partially support our hypothesis and imply that
different implant designs do not lead to strong differ-
ences in the range of motion and the location of center
of rotations. In contrast, facet forces appeared to be
strongly dependent on the implant design. However, due
to the great variability in facet forces reported in the
literature, together with our results, we could speculate
that these forces may be more dependent on the indi-
vidual spine geometry rather than a specific implant
design.
Keywords Mobile artificial discs
Finite
element analysis
Arthroplasty devices
Back pain

Implants
Introduction
Lumbar total disc arthroplasty devices have been intro-
duced to clinics as an alternative to fusion with the aim of
preserving spinal motion. This should also alleviate back
pain, decrease the incidence of adjacent segment degen-
eration, avoid complications related to fusion, and allow
early return to function [3, 14, 15, 26, 33]. Due to these
advantages, a large number of different arthroplasty devi-
ces have been developed and are currently available and in
clinical use. The first successful arthroplasty device was the
SB Charite disc (Depuy Spine; Raynham, MA, USA).
Other concepts followed such as Prodisc (Synthes; Paoli,
USA), MaverickTM (Medtronic; Minneapolis, MN, USA),
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Flexicore (Stryker; Kalamazoo, MA, USA), Mobidisc
(LDR medical; Troyes, France), and Activ L (Aesculap
AG; Tuttlingen, Germany).
Most artificial discs consist of two metallic endplates
and a polyethylene core. The core is either separated
between both endplates (=unconstrained design), partially
or intrinsically connected with the lower endplate (=semi-
constrained or constrained design). The Charite disc is
representative of an unconstrained and the Prodisc
prothesis of a constrained design.
The unconstrained design allows the adjacent vertebrae
to translate relatively to each other without any accompa-
nying rotation [11]. This behavior leads to a moving
instantaneous center of rotation (ICR) and therefore,
mimics the physiological behavior of a functional spinal
unit, as supposed by Cunningham et al. [3]. In contrast, it
is stated that the constrained configuration causes a fixed
ICR. This assumption is explained in the way that the
segmental translation occurs concurrently with rotation
given by the radius of the inner core. We disagree with this
assumption, because the kinematical behavior of an
implanted spinal segment is not only dependent on the
implant itself. The articulating facet joints, which also play
a major role for spinal load transmission, the remaining
soft disc tissue, and the elastic behavior of the adjacent
bony structures also influence the spinal motion behavior
and therefore, control the location of the ICRs.
We therefore proposed the hypothesis that different
design concepts do not lead to substantial differences in the
location of the ICRs. We furthermore hypothesized that the
different implant designs lead to a similar range of motion
(RoM) and to similar facet joint forces. We investigated
our hypotheses in a finite element (FE) analysis.
Materials and methods
Implants
In the current study, we used three different implant
designs: The first design was the SB Charite III disca
three piece construct comprised of a biconvex core
sandwiched between two concave endplatesrepresenting
an unconstrained design. The second implant, also rep-
resenting an unconstrained design, was a newly developed
disc prosthesis: Slide-Disc (Weber Instrumente GmbH;
Emmingen-Liptingen, Germany) (Fig. 1). Similar to the
Charite disc, the Slide-Disc consists of two endplates
and a mobile sliding core. This core is articulated with the
upper endplate by a spherical fully congruent surface. In
contrast to the Charite disc, the articulation between the
core and the lower endplate is realized by a slightly
curved contact surface. This allows the core to move
almost freely within the transversal plane. The developers
assume that the Slide-Disc is able to better reproduce
the ICRs of a healthy intact spinal segment, in particular
for axial rotation than the Charite, as a result of the
freely sliding core. For axial rotation it has been found
from in vitro and FE studies that the ICR migrates outside
the disc close to the facet joints under higher load con-
ditions [9, 27, 34]. The third implant design was a
modification of the Slide-Disc. Here, the inner core was

Fig. 1 Left Finite element mesh

of the L4-5 lumbar spinal
motion segment with the
implanted Slide-Disc. Right
Detail view of both investigated
dynamic disc implants: Slide-
Disc (above) and SB Charite
III (below). The location of both
implants was varied by 4 mm in
both an anterior and posterior
direction. Label A indicates the
contact areas which were varied
between standard unilateral
contact (normal pressure equals
zero if separation occurs) and
bonded (contact surface is
always attached to the target
surface along the normal and
tangent directions)

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rigidly connected to the lower endplate representing a
constrained design.
Finite element modeling
A three-dimensional, non-linear FE-model of an intact L4-
5 ligamentous human lumbar motion segment was used in
this study (Fig. 1). This FE-model has been used previ-
ously to investigate a number of clinically relevant issues
[2832]. The model validation has been extensively docu-
mented in these studies. In the following is given a brief
description of this FE-model.
The commercial software ANSYS 11.0 (ANSYS INC.,
Canonsburg, PA, USA) was utilized to perform the FE
analysis. The model consists of two vertebrae, the inter-
vertebral disc, and the seven main ligaments. The inter-
vertebral disc considers the nucleus pulposus and the
surrounding annulus fibrosus. The annulus was modeled as
a composite of solid matrix with embedded fibers, which
are organized in seven concentric rings around the nucleus.
Fibers and ligaments were represented by unidirectional
spring elements with a non-linear force-deflection curve
and no compression capabilities. The articulating facet
surfaces were modeled using surface-to-surface contact
elements in combination with the penalty algorithm with a
normal contact stiffness of 200 N/mm and a friction
coefficient of zero. The facet cartilage layer was assumed
to yield a thickness of 0.2 mm. The initial gap between the
cartilage layers was assumed to be 0.4 mm. The capsular
ligament was simulated by using spring elements with a
non-linear force-deflection curve forming a ring around the
articular contact; they linked the borders of the inferior
vertebra superior articular process to the borders of the
superior vertebra inferior articular process.
Implant modeling
Both implants were meshed using eight-node isoparametric
solid elements. The spiked endplate surfaces of both
implants were simplified to a flat surface. The Slide-Disc
and the Charite disc are available in different sizes. For
our simulations, we used the Slide-Disc type III with a
height of 11 mm and a lordotic angle of 4 and the Charite
III with an approximate height of 13 mm and a lordotic
angle of 5.
A standard unilateral contact was assumed at the arti-
cular surface between the core and the concave metallic
endplates. A friction coefficient of 0.02 was chosen for
both implants [7]. For the Charite endplates, a chrome-
cobalt alloy was assumed with a Youngs modulus of
300 GPa and a Poissons ratio of 0.27 [7]. The inlays were
represented by a polyethylene core (ultra high molecular
weight polyethylene (UHMWPE)) with a Youngs
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modulus of 2 GPa and a Poissons ratio of 0.3 [7]. A
titanium alloy (Ti6Al4 V) with a Youngs modulus of
113.8 GPa and a Poisson ratio of 0.3 was assigned to the
Slide-Disc endplates. For the inlay a Youngs modulus of
2 GPa and a Poissons ratio of 0.3 were similarly chosen.
All the values for the SlideDisc were provided by Weber
Instrumente.
Two cases were simulated for the Slide-Disc. In the
first case, the inner core was assumed to be movable (Slide-
Disc mobile core: SD-MC), as it is intended by the com-
pany. In the second case, the inner core was rigidly fixed
(bonded) at the lower metallic endplate of the implant,
simulating a constrained design (Slide-Disc immobile core:
SD-IMC), as it is realized by the ProDisc.
Implantation
Disc placement procedure for both implants requires an
anterior surgery for implantation. The protocol involves the
stepwise removal of the anterior longitudinal ligament, the
anterior portion of the annulus, and the entire nucleus
pulposus. Only the posterior and lateral portion of the
annulus remains in place. To mimic this surgical proce-
dure, the elements representing these structures were
removed in the FE-model (Fig. 1).
Investigation of different implantation situations
First, both implants were integrated in the intervertebral
space in a geometrically central position. Subsequently, the
locations of both implants were varied by 4 mm in both an
anterior and posterior directions (Fig. 1).
The contact condition between the metallic endplates
and the adjacent bony structures was verified between
perfect bond and standard unilateral contact (indicated by
the label A in Fig. 1) with a friction coefficient of 1. While
a bonded contact represents a perfect bone osteo-integra-
tion between the metallic endplates and the adjacent ver-
tebrae, the standard contact investigates the treated
segment right after the surgical procedures. The latter
additionally represents the poorest osteo-integration, which
implies that a gap between implant and adjacent bony
endplates may exist under certain loads.
Loading and boundary conditions
The inferior endplate of the lower vertebral body was
rigidly fixed. An axial compression preload of 1,000 N was
applied simulating upper body weight plus muscle forces.
This load was applied using the follower load technique
[19], which is thought to have a similar stabilization effect
as that of the local muscles [23]. The load follows the
curvature of the spine through the proximities of the ICRs
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and therefore, avoids the generation of additional larger
moments. This was realized by using connector elements
which were spanned between the centers of both vertebral
bodies. Subsequently, the spinal segment was loaded with
unconstrained moments of 7.5 Nm in the sagittal, lateral,
and axial directions simulating flexion, extension, lateral
bending, and axial rotation.
Data analysis
1. Range of motion
2. Facet joint force and pressure distribution in the facet
surfaces
The resulting forces for each contact element in one
facet joint were added together to give a total facet force
(FF). In each facet surface the pressure distribution was
displayed independent of the calculated maximum value
and divided into a pressure area greater than 70%, greater
than 40%, and less than 40% of the maximum value.
3. Center of rotation
The ICR was calculated according to the Reuleaux
method [21]. This was performed by intersecting the per-
pendicular vectors from the midpoint of the translation
vectors for two nodes in the upper vertebral body. The
applied moments were incrementally increased from zero
to the predetermined maximum value of 7.5 Nm, which
were attained in ten equally sized incremental steps. The
ICRs were evaluated between two consecutive steps. In the
corresponding figures, the ICRs were only shown for three
different load magnitudes: 1.5, 3.75, and 7.5 Nm in relation
to their previous step, i.e., load magnitudes of: 0.75, 3.00,
and 6.75 Nm, respectively.
intact situation, we defined a standard evaluation scale for
all result parameters. This scale was defined as follows: A
difference between 0 and 15% indicated a slight difference,
between 16 and 30% indicated a moderate difference, and
from 31% to higher values indicated a large difference. All
results were adapted according to this scale.
Range of motion
Except for extension, the models predicted only small and
moderate inter-implant differences, particularly for both
Slide-Disc designs, where the maximal percentage differ-
ence was 15% (Fig. 2). For extension, a large difference of
about 45% was calculated between both Slide-Disc
designs and the Charite.
In flexion, all implants led to an averaged decreased
RoM of 22% compared to the intact state when the artificial
discs are centrally placed. In extension, only the Charite
caused a strong increase of 52%, while both Slide-Disc
designs showed a good representation of the intact state. In
lateral bending, the different Slide-Disc designs led to a
slight increase of the RoM. The RoM predicted by the
Charite is 36% higher than for the intact segment. In axial
rotation, all three implant designs restored almost to the
intact state.
In flexion, placing the implants more posteriorly led to
an increased RoM and a better representation of the intact

Model verification

Before undertaking the present study we performed mesh

convergency tests with both disc prostheses. In previous
investigations we also conducted convergency tests with
the facet joints. As critical result parameters for both cases
we used the RoM and the ICRs, and for the facet joints we
additionally used the contact pressure, the pressure distri-
bution, and the contact forces. The element edge length
was reduced until the percentage difference of these critical
results between two consecutive mesh densities was less
than 2%.

Results Fig. 2 Influence of implant position in an antero-posterior direction

on range of motion in flexion, extension, lateral bending, and axial
rotation. The dashed line indicates the range of motion of the intact
In order to better interpret the differences between the model. MC Slide disc with mobile core and IMC Slide disc with
individual implant designs and between the implanted and immobile core

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state. In extension only the Charite was influenced by the
implant position. Similar to flexion, a more posteriorly
placed implant led to a better representation of the RoM
calculated for the intact state. A similar behavior was seen
for lateral bending. While both Slide-Disc designs
showed only a slight influence on the implant position, the
Charite predicted a strong influence. In axial rotation, the
implant position did not greatly influence the RoM.
Facet joint forces
In flexion, the facet joints remained unloaded for the intact
model (Fig. 3). In contrast, the presence of any of the disc
prostheses led to high facet forces, especially for the
Charite. Here, the calculated force was 138 N when the
implant is centrally placed. Up to 32% inter-implant dif-
ferences were calculated. In extension, much larger inter-
implant differences were found than was indicated under
flexion. The models predicted strongly increased forces for
the SD-MC (60%) and a strong decrease of 70% for the
Charite compared to the intact state. Totally unloaded
facet joints were predicted for the SD-IMC. In lateral
bending, strong inter-implant differences were also calcu-
lated. Compared to the intact situation the force decreased
by 4% for the Charite and 83% for the SD-IMC. In
contrast, the facet joint forces strongly increased by 214%
for the SD-MC prosthesis. In axial rotation, only small
Fig. 3 Influence of implant position in an antero-posterior direction
on acting forces in the facet joints in flexion, extension, lateral
bending, and axial rotation. The dashed line indicates the facet joint
forces of the intact model. In flexion, the facets remained unloaded.
MC Slide disc with mobile core and IMC Slide disc with immobile
core
1699
inter-implant differences up to 15% were calculated. The
artificial disc models caused an increase of 46% for the SD-
MC, 32% for the Charite, and 27% for the SD-IMC
compared to the intact state.
Changing the position of the artificial discs affected the
facet joint forces for all investigated loading cases differ-
ently. The SD-MC showed a slight effect for flexion,
extension, and axial rotation. In lateral bending, strong
differences up to 36% of the resulting forces were calcu-
lated. Here, the forces decreased when shifting the implant
posteriorly.
The influence of different implant positions was still
stronger emphasized by the Charite and the SD-IMC,
especially in extension. For the Charite we calculated
completely unloaded facets when shifting the implant
posteriorly, whereas, a more anterior position increased the
facet forces by 240%. The SD-IMC showed the largest
effect in flexion. Here the implant led to a force increase of
110% when shifting the disc from the most anterior to the
most posterior position.
Pressure distribution in the facet surfaces
In flexion and in extension, both the left and the right facet
joints were equally loaded: in flexion more in the central
region (Fig. 4) and in extension more in the inferior tip of
the facet (Fig. 5). In lateral bending, the facet joint was
loaded on the ipsilateral side of bending for the intact
model. The contralateral side remained almost unloaded
(Fig. 6). The different artificial discs also caused loaded
facets on the contralateral side. However, the calculated
forces were always smaller compared to the ipsilateral side.
For the intact situation and for all disc implants, left axial
rotation led to an increase of contact forces on the right
facet joint, while the left facet remained nearly unloaded
(Fig. 7). Only for small torsional moments, forces for the
left facet were calculated. These forces were mainly pro-
duced by the applied preload.
Center of rotation
In flexion, the intact model predicted ICRs in the mid-
height of the disc (Fig. 4). The ICR was located in the
center of the disc for small moments (up to 1.5 Nm). With
increasing moment (up to 7.5 Nm) the ICR moved slightly
toward the anterior direction. The location of the ICR is
only slightly affected by the presence of any of the
investigated disc prostheses. For small moments they are
shifted slightly caudally close to the superior endplate of
the lower vertebral body and slightly altered their positions
with increasing flexion, except for the SD-MC model
where it moves somewhat cranially close to the inferior
endplate of the upper vertebral body.
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Fig. 4 Predicted location of the

center of rotations (ICR)
(above) and the resulting
pressure distribution in the
inferior facet of L4 (below) with
increasing flexion. The ICRs are
shown for three different
moments (M): 1.5, 3.75, and
7.5 Nm in relation to the
moment resulting from the
previous sub-step: 0.75, 3.00,
and 6.75 Nm, respectively. The
dark points show the current
ICR for each of the three
moment intervals and the light
points show the ICR always for
the first moment interval (0.75
1.5) to illustrate how the ICRs
migrate with increasing load.
The maximum forces for each
facet joint and the pressure
distribution are shown for
moments of 1.5, 3.75, and
7.5 Nm. MC Slide disc with
mobile core and IMC Slide disc
with immobile core

In extension, the ICRs of the intact model were also
located in the center of the disc for small moments of
1.5 Nm (Fig. 5). With increasing moment, the ICR
migrated slightly posteriorly. Under the maximum moment
of 7.5 Nm the ICR was calculated as being in the posterior
nucleus. Similar to flexion, the differences in ICR locations
between the investigated prostheses are small. The ICRs
were located almost in the center of the disc for small
moments. With ongoing extension moment, the ICRs
migrated towards the lower vertebral body and moved
slightly in the posterior direction.
In lateral bending, the ICRs of the intact spinal model
were calculated as being almost in the center of the disc for
small moments and migrated towards the side of the
bending with increasing moment (Fig. 6). Under the
maximum moment of 7.5 Nm, the ICR was located on

Fig. 5 Predicted locations of

the center of rotations (ICR) and
the resulting pressure
distribution in the inferior facet
of L4 with increasing extension.
Explanations for the ICRs see
Fig. 4. The maximum forces for
each facet joint and the pressure
distribution are shown for
moments of 1.5, 3.75, and
7.5 Nm. MC Slide disc with
mobile core and IMC Slide disc
with immobile core, FF Facet
joint forces

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Fig. 6 Predicted locations of

the center of rotations (ICR) and
the resulting pressure
distribution in the inferior facet
of L4 with increasing right
lateral bending. Explanations
for the ICRs see Fig. 4. The
maximum forces for each facet
joint and the pressure
distribution are shown for
moments of 1.5, 3.75, and
7.5 Nm. MC Slide disc with
mobile core and IMC Slide disc
with immobile core, FF Facet
joint forces

the right side of the disc, near the inferior endplate of L4.
For small moments, the artificial disc models predicted
ICRs also almost in the center of the disc. With increasing
moment, the SD-MC showed a larger upward movement
towards the center of the L4 vertebral body. The Charite
and the SD-IMC altered slightly their locations in the
direction of the lower vertebral body.
In axial rotation, the ICRs were found close to the center
of the disc for small moments (Fig. 7). With increasing
moment, the ICR migrated to the posterior direction. With
a moment of 7.5 Nm the model predicted an ICR location
outside of the disc, close to the compressed facet joint. Up
to a moment of approximately 5 Nm all three artificial
discs showed similar tendencies: with increasing moment,

Fig. 7 Predicted locations of

the center of rotations (ICR) and
the resulting pressure
distribution in the inferior facet
of L4 with increasing left axial
rotation. Explanations for the
ICRs see Fig. 4. The maximum
forces for each facet joint and
the pressure distribution are
shown for moments of 1.5, 3.75,
and 7.5 Nm. MC Slide disc with
mobile core and IMC Slide disc
with immobile core, FF Facet
joint forces

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the location of ICRs migrated to the postero-lateral direc-
tion of the disc. However, for the maximum moment of
7.5 Nm, only the SD-MC prosthesis led to an ICR location
outside the disc, close to the compressed facet joint.
In flexion and extension, placing the implant ventrally
showed a shift of the ICR in the anterior location, while a
more posterior implant position caused the ICR to migrate
slightly posteriorly. For both load directions, the SD-IMC
led to ICRs which were located in the region of the adja-
cent lower vertebral body. In lateral bending, the ICRs
were calculated to be more in the adjacent lower bony
structures when shifting the implant anteriorly as well as
posteriorly. The ICR pattern caused by the SD-IMC was
spread over a much larger area compared to the intact
situation. Axial rotation led to a shift of the ICR slightly in
the anterior location.
Perfect bond and standard unilateral contact
Changing the contact condition between the metallic end-
plates and the adjacent bony endplates did not strongly
affect the results, neither for the central nor for the different
implant positions. A maximum difference of 2% for the
facet joint forces was calculated.
Discussion
The biomechanical behavior of dynamic non-fusion
implant systems were often tested in experimental in vitro
studies [10, 12, 13, 17, 18] and evaluated by analyzing
clinical radiographs [14]. These studies were principally
focused on the estimation of remarkable changes in RoM at
the treated and adjacent segments. The authors of these
studies showed that the various disc prostheses generally
preserve the mobility at near physiological level, for both
constrained and unconstrained designs, which was con-
firmed by our FE simulations. However, the RoM alone is
not sufficient to evaluate the spinal stability. Therefore,
authors used the ICR as an additional parameter to analyze
the motion behavior of the treated segment [5, 6, 20]. In a
FE analysis, we estimated the measurement error, which is
always given when ICRs are experimentally determined
[27]. In this study we showed that a small domain of input
data led to severe changes on the position of the ICR. This
implies that simply alignment of two X-rays generated in
different postures, as done in clinical practice, is not suf-
ficient to determine the ICR. Indeed, a high accuracy is
needed because of small movements which in particular
occur when the spine is exposed to axial rotation. Data
evaluations using FE models with a high validity and
predictability are a suitable tool for evaluating ICR loca-
tions, since there are no further measurement errors.
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Eur Spine J (2009) 18:16951705
The results of our FE study supported our hypothesis in
that the different mobile implants do not lead to substantial
differences in the location of the ICRs. Except in axial
rotation, the ICRs of all three implant designs mimicked
almost the non-treated intact situation. The implant with
the constrained core did not cause a fixed ICR. This result
can be explained as follows: The artificial disc should not
be considered separately but with the surrounding elastic
structure. Our FE results showed that the adjacent bony
endplates may strongly deform under certain loads. At the
same time high forces in the facet joints occurred, espe-
cially in axial rotation (Fig. 3). These high facet forces in
combination with the endplate deformation allow the
adjacent vertebrae to translate relatively to each other and
therefore, lead to a moving ICR.
In axial rotation, the different implant designs showed a
slightly different behavior. While the Charite and SD-
IMC prostheses predicted ICRs inside the disc, the SD-MC
prosthesis caused an ICR location outside the disc, close to
the compressed facet joint and therefore, better mimicked
the intact situation. This is caused by the sliding core.
Under small moments no differences in ICRs were calcu-
lated between SD-MC and SD-IMC (Fig. 7). Under these
small moments, the inner core of the SD-MC prosthesis
moved only marginally within the implant (less than
0.1 mm). From approximately 5 Nm upward to 7.5 Nm,
the SD-MC led to a sudden change of the resulting ICR
locations. This moment increase caused the inner core to
migrate 0.8 mm to the ipsi-lateral direction. The movement
of the core is the crucial factor, which caused an ICR
migration to the compressed facet joint.
In flexion, extension, and lateral bending we calculated a
cranial-caudal migration of the ICRs for the SD-MC. In the
first instance such a result would seem unexpected, because
an implant which is restricted to a transversal movement of
the inner core should only allow the migration of the ICRs
in same direction. The cranial-caudal migration can,
however, be induced by two different parameters. One
point is that the lower metallic endplate is slightly con-
cavely curved allowing the core to move slightly vertically
during transverse motion. A second point is that the adja-
cent bony structures are deformed during loading so that
the relative distance of the core in relation to the bony
structures is altered.
Both results, a posterior migration of the ICRs towards
the facet joints as well as the constrained core did not lead
to a fixed ICR, seem to be caused by a lift-off of the
metallic endplate from the core. However, this phenome-
non did not occur in all load situations. The pressure dis-
tribution of the core and the metallic endplates was
analyzed by the authors and both parts were always found
to be under stress, which is an indication that this lift-off
would not occur. Such a lift-off was found in a previous
Eur Spine J (2009) 18:16951705
study by us (unpublished data), however, for only one
specific load direction: pure moment in extension without
an axial compression preload. In this case, the facet joints
led to an opening of the implant. We made additional
investigations in which we defined a no separation con-
tact condition between the metallic endplates and the inner
core. The results were the same as that found in our study.
In addition, no tensile stresses between the metallic end-
plates and the inner core were calculated, which would
indicate a separation between both contact pairs.
In contrast to the RoM and ICRs, the facet joint force
strongly depends on the implant design. For all load
cases, our model predicted higher facet joint forces for the
implants with an unconstrained core (Charite and SD-
MC) compared to an implant with a constrained core
(SD-IMC). This result can be explained by the resulting
forces passing through the implant itself. An uncon-
strained design transfers only normal forces from the
upper to the lower vertebral body. In contrast, a con-
strained design additionally transfers shear forces through
the implant and therefore, is stronger loaded than the
unconstrained design. Our FE model predicted implant
forces in flexion, extension, lateral bending, and axial
rotation of 623, 1,013, 785, and 852 N for the SD-MC,
and forces of 985, 1,130, 945, and 963 N for the SD-IMC
model, respectively. On average, the constrained implant
is 19% higher loaded than an unconstrained implant. This
force difference is compensated by the articulating facet
joints meaning that higher implant forces resulted in
lower facet forces.
The resulting forces in the facet joints have been dis-
cussed at length in the literature. While Zander et al. [35]
calculated a strong increase of the acting forces in the
facets in extension for the Charite, Grauer et al. [8], Goel
et al. [7], and Moumene and Geisler [16] found a slight to
moderate decrease in these forces for the same implant.
These opposing findings were intensified by our results. For
the Charite we predicted even less forces, down to
unloaded conditions. Whereas, with the Slide-Disc-MC
we determined a moderate increase in the resulting forces.
In the case of the ProDisc (which corresponds to the
Slide-Disc-IMC in our study) these inconsistencies were
similarly found. For this implant, both Moumene and
Geisler [16], and Zander et al. [35] predicted a slight
decrease in the acting forces, whereas, the study results of
Rundell et al. [25] as well as our results indicated either
almost or completely unloaded facets. In flexion, Zander
et al. [35] found no forces in the facets for intact as well as
for all the investigated implants. In contrast, Grauer et al.
(2006) indicated that the Charite led to a slight force in
flexion, although more details were not provided. The
study results of Rundell et al. [25] for the ProDisc toge-
ther with our results for all three implant designs predicted
1703
strong facet forces. The same inconsistencies can be seen
for lateral bending and axial rotation.
One reason for such a large variation in the results may
have arisen through the use of FE models based on dif-
ferent geometries. Consequently, slight changes in the gap
distance, the degree of curvature or the facet orientation
can lead to completely different results. In our investiga-
tions the gap size was set at 0.4 mm. An increase in the gap
of only 0.1 mm led to an average decrease of 45% for all
the three implants. A probabilistic FE analysis by Rohl-
mann et al. [22] confirmed our supposition. The authors
investigated how, for example, the facet forces are influ-
enced by parameters such as the implant position, the
presence of scar tissue or the gap size in the facet joints
when implanting the ProDisc. In extension, Rohlmann
et al. reported a zero force for the instrumented segment in
70% of all investigated cases (1,000 randomly generated
FE models), which is in agreement with our predictions.
Rohlmann et al. suggested that the resulting forces are
strongly dependent on the gap size. Furthermore, the
authors found that in flexion the ProDisc caused facet
forces in 37% in the instrumented segment, which is also
confirmed by our predictions.
The described methodology has some assumptions and
limitations. In the current study, we decided on a follower
load magnitude of 1,000 N, which contrasts with our pre-
vious studies in which we only simulated a follower load of
500 N. The reason for this is that Rohlmann et al. [24]
suggested in a FE study that a load of 500 N was not
sufficient for simulating flexion, since it did not take into
account the global muscle forces. However, when the
authors increased the load up to 1,175 N, they obtained
results that were comparable with in vivo data. In com-
parison to 500 N, this increase had only a minor influence
on the RoM and a neglectable effect on the resulting facet
forces. For extension when they simulate a follower load of
500 N they were already able to calculate an acceptable
intradiscal pressure. However, the calculated facet joint
forces under this 500 N were much lower in comparison to
the simulation when the global muscle forces were con-
sidered, which Rohlmann et al. indicated as being a more
physiological load application. A more realistic facet
joint force was much more important in our study than the
intradiscal pressure, because the facet joint forces have a
stronger influence on our results than the disc pressure,
which are moreover absent in our different implant models.
The follower load was applied to the spinal segment by
using connector elements which passed almost the ICRs
(center of the disc) found for small moment applications
and therefore, avoid the generation of additional larger
moments. However, the ICRs are not fixed in space and
changed with motion. This may produce additional
moments when further bending or torsional moments are
123
1704
applied. The current study showed that the ICRs are mostly
located in the center of the disc, except for axial rotation.
Axial rotation produced the largest changes in the ICRs
during loading, meaning that the ICRs migrate from the
disc center to the corresponding compressed facet joint.
This larger distance generates additional moments for the
motion segment, which cannot be neglected.
We used a fixed combination of material properties for
the different artificial disc implants as used in a prior FE
study of Goel et al. [7] and defined by Weber Instrumente.
The exact values of the Youngs modulus and of the
Poissons ratio of the titanium alloy and the UHMWPE
were neither published by the company Depuy Spine nor
known by Weber Instrumente and therefore, may slightly
differ from the values used in the current study. Different
values might have a small influence on our findings.
The form, such as the radius and the size of the inlay, of
an actual fixed core design was not considered in the cur-
rent study and therefore a specific functional goal of this
design is lacking. The advantage of this approach lies in the
fact that the actual functional difference between a fixed
and a mobile core can be determined independently of
other inter-implant differences. In our study the only dif-
ference between mobile and immobile core design was a
single condition in the contact definition (standard vs.
bonded). If we had used the ProDisc prosthesis as an
example of a fixed-core design, other parameters would
have had an influence on our results and therefore would
have obscured the differences that we found.
Our controversial findings in facet forces raise the
question of the reliability of deterministic FE studies,
which are characterized by a fixed configuration of material
and geometrical properties. The results generated by this
type of model should always be interpreted with caution,
and certain results, such as specific pressure values at the
facet surfaces should not be interpreted in a clinical con-
text; they simply provide a trend. Deterministic models are,
however, legitimate when directly comparing the bio-
mechanical outcome of two different disc prosthesis, with
the qualification that a small modification of the geometry
could produce the opposite results.
Conclusions
Total disc arthroplasty inherently alters the kinematics at
implant level for all clinical used prostheses. Compared to
these alterations, our finite element model predicted that
inter-implant differences are small regarding the RoM and
ICR. In contrast, facet joint forces are strongly dependent on
the implant design. In contrast, facet forces appeared to be
strongly dependent on the implant design. However, due to
the great variability in facet forces reported in the literature,
123
Eur Spine J (2009) 18:16951705
together with our results, we could speculate that these forces
may be more dependent on the individual spine geometry
rather than a specific implant design. In order to be able to
make a suggestion, it is necessary to know which load
directions of the spine and which parameter is most signifi-
cant. If it is, for example, flexion and the RoM, it does not
make any difference which implant design is used. If it is in
contrast axial rotation and the ICR, our results suggest the
need of a mobile core design.
Acknowledgments This study was financially supported by the
German Research Foundation (Wi 1352/14-1). The authors would
like to thank Depuy Spine (Raynham, MA, USA) and Weber
Instrumente GmbH (Emmingen-Liptingen, Germany) for the supply
of their implants. We also would like to thank Dr. Robert Blakytny for
his help in editing the manuscript.
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